RU2801414C1 - Method of the treatment of extrasphincter pararectal fistulas - Google Patents

Abstract

FIELD: medicine; coloproctology.

SUBSTANCE: under local anaesthesia with potentiation with a bellied probe, the fistulous passage is revised through the external opening, the fistulous passage is washed with a 0.05% aqueous solution of chlorhexidine, followed by the treatment of the passage with a Volkmann spoon. Through the incision in the projection of the intersphincteric space, the fistulous tract is crossed, not reaching the internal opening of 0.5 cm, which is turned into the intestinal lumen with a single-pronged hook, and the internal opening of the fistulous tract is sutured by applying a Z-shaped suture with the capture of the muscles of the internal sphincter, followed by ablation of the distal fistulous tract with a Lakhta-Milon surgical laser intraluminally using a light guide with circular radiation with a length waves 1470 nm, power 9 W, at a speed of 1 mm/s.

EFFECT: method makes it possible to treat a fistulous tract with a pronounced sanitizing and coagulating effect without damage to the sphincter, prevents the formation of a rough scar, a residual cavity, and reduces the risk of recurrence.

1 cl, 1 ex

Description

The invention relates to medicine, namely to coloproctology, and can be used in the surgical treatment of patients with chronic paraproctitis.

Fistulas of the rectum is one of the most common coloproctological diseases, their frequency ranges from 15% to 30% [Zhukov B.N., Shabaev V.N., Isaev V.R., Lysov N.A. Coloproctology. - Samara, Samara State Medical University, 1999, - 132 p.; Rivkin V.L. et al. "Hemorrhoids and other diseases of the anal canal", M., 1994, - 238 p.]. At the same time, fistulous forms of paraproctitis occur in 28% of cases among all proctological diseases [Zhukov B.N., Shabaev V.I., Isaev V.R., Lysov N.A. Coloproctology. - Samara, Samara State Medical University, 1999, - 132 p.; Rivkin V.L. et al. "Hemorrhoids and other diseases of the anal canal", M., 1994, - 238 p.].

Depending on the location of the fistulous passage in relation to the external sphincter of the anus, intra-, trans- and extrasphincteric fistulas of the rectum are isolated [Vorobiev G.I. Fundamentals of coloproctology. - Rostov-on-Don: Phoenix, 2001, - 414 p.]. Extrasphincteric fistulas are high-level fistulas, in which the course goes around the outside of the sphincter of the anus. The treatment of complex (extrasphincteric) fistulas remains an urgent task, since the fistulous passage is located high, it can occupy several cellular spaces with the formation of streaks, and there is a risk of sphincter injury during the operation [Semionkin E.I. Coloproctology. - M.: ID Medpraktika. - M., 2004, - 224 p.].

A characteristic feature of fistulas of the rectum is the presence of the fistulous tract itself, which can be located outward from the sphincter fibers, pass through the sphincter fibers or medially relative to the sphincter fibers, as well as the presence of an internal fistulous opening opening into the intestinal lumen, and an external fistulous opening on the perianal skin. All pararectal fistulas are characterized by the presence of perifocal inflammation in the pararectal tissue, as well as the presence of cicatricial changes in the rectum and surrounding tissues.

Treatment of pararectal fistulas is still a difficult problem. In this category of patients, fistula recurrences often occur, and the postoperative period is often complicated by the development of anal sphincter insufficiency. The emergence of minimally invasive methods for the treatment of anal fistulas has led to the rapid introduction of these techniques among proctologists in Western Europe, as evidenced by numerous publications. The emergence of radial laser fibers with uniform emission of laser radiation due to microlenses at the end of the working part opens up new prospects for the minimally invasive treatment of rectal fistulas, as it allows reliable ablation of a large diameter fistulous tract. Many different methods of treatment of patients with this pathology have been proposed. However, most of the techniques are accompanied by significant surgical trauma, a long recovery period and frequent recurrence of the disease. The greatest difficulty in the method of surgical treatment of patients with complex pararectal fistulas lies in the direct involvement of the anal sphincter in the pathological process, which leads to a high risk of anal incontinence (up to 50%) [Fundamentals of coloproctology / under. ed. G.I. Vorobyov. - M.: LLC "Medical Information Agency", 2006. - S. 135-144]. For this reason, the development of new effective and less traumatic methods of treating patients of this nosological group is an urgent problem of modern colorectal surgery.

A known method of minimally invasive treatment of complex pararectal fistulas, proposed by Solovyov O.L. (RF patent No. 2440164 dated September 23, 2010), which includes ultrasonic treatment with simultaneous supply of the liquid phase and subsequent evacuation of the liquid phase, while first conducting a study of the fistulous tract, determining its direction and the presence of external and internal holes, then sequentially process each fistulous passage through the external opening, with obturation of the external opening of the untreated fistulous passage, at least twice, with an interval of two days, treatment is carried out for 40-80 seconds with ultrasonic vibrations with a frequency of 20-60 kHz, and an alcohol solution in amount of 10-20 ml, depending on the size of the fistula, which is served at a rate of 0.25 ml per second.

Also known is a method for the treatment of complex forms of rectal fistulas using a modified Filac technology (Khitaryan A.G., Kovalev S.A., Kislov V.A., Romodan N.A., Alibekov A.Z., Orekhoa A.A. ). The method was performed as follows. Taking into account the data of ultrasound and MRI, the main fistulous tract was found in the surgical wound and crossed at a distance of 1 cm from the entrance to the anal sphincter array, where the fistulous tract is no longer tortuous. The fistulous tract was catheterized with an Elves Radial Biolitec spherical laser light guide and then laser ablation of the fistulous tract was performed with a laser with a wavelength of 1470 nm, a power of 6 W, in a pulsed mode "0.9 sec pulse, 0.1 sec interval", with a total energy of 200 J, reaching ablation and decontamination of the latter, without damaging the anal sphincter and the fibrous membrane of the fistula. Then the postoperative wound was sutured by suturing the edges of the skin wound to the underlying tissues of the perineum along its entire length with absorbent thread 1.0. The wound in the postoperative period healed by secondary intention.

Known methods have a number of disadvantages:

- necrosis of the muco-muscular flap, eruption of sutures when performing this method inevitably leads to a recurrence of the fistula;

- performance of the operation and adequate closure of the internal opening of the fistula in this way is not feasible with cicatricial changes covering more than the semicircle of the rectum.

As a prototype, we adopted a method of surgical treatment of fistulas of the anal canal (Fedotov DV, patent No. 2558454 dated 08/14/2014). A patient under anesthesia with a rectal speculum inserted into the rectum is performed with a divulsion of the sphincters. A dye is injected into the external fistulous opening and the localization of the internal fistulous opening is determined. A bellied probe is passed through the external fistula opening, to destroy adhesions inside the fistula canal and expand the lumen, the canal is washed with a 3% hydrogen peroxide solution using a sterile syringe. Then the fistulous canal is treated with laser radiation from a Lakhta-Milon 970 nm 25 W diode laser. The choice of a surgical laser is determined by the fact that the wavelength of the working radiation of 970 nm falls on the local absorption maximum of the biological tissue. In addition, the risk of damage to underlying organs by laser radiation is reduced. Radiation provides a good coagulating effect. To do this, a laser electrode with a circular spectrum is passed through the fistulous canal to the inner hole to the inner hole. Start laser processing with a laser power of 14 W, a pulse duration of 900 m/s and an interval between pulses of 10 m/s. Initially, 6 pulses are applied, then the light guide is pulled back by 3-5 mm, and the cycle is repeated. During the entire procedure, the radiation is not turned off. The electrode head is brought to the external fistulous opening, not reaching 5-10 mm, so as not to burn the skin of the perineum. It is important to observe the specified operating parameters, since if the specified parameters are reduced, the desired result will not be obtained, i.e. there is no coagulation of the tissues of the fistulous canal. On the contrary, with an increase in the power and time of laser exposure, a burn of the surrounding pararectal tissue occurs at the point of impact, or a perforation of the fistulous canal occurs. In order to prevent the laser fiber from sticking to the wall of the fistula canal during the procedure and to minimize the risk of injury, the pulse is not stopped until the fiber is removed. The internal fistulous opening is sutured with a double-row catgut suture.

The prototype has several disadvantages:

- when using the method with complex fistulas, a residual cavity is formed, which increases the risk of developing purulent complications (infiltrates, abscesses and recurrence of fistulas);

- there is a risk of eruption of sutures with the development of cicatricial deformity of the intestine and, at the same time, insolvency;

The aim of the invention is to reduce the duration of treatment, prevent recurrence of the disease and postoperative complications and improve cosmetic results.

The objective of the invention is the development and implementation of a new method of minimally invasive treatment of extrasphincter pararectal fistulas.

This goal is achieved by the fact that under local anesthesia with potentiation with a bellied probe, an audit of the fistulous tract is carried out through the external opening, the fistulous tract is washed with a 0.05% aqueous solution of chlorhexidine, followed by treatment of the tract with a Volkmann spoon, the fistulous tract is crossed through the incision in the projection of the intersphincteric space , not reaching the internal opening of 0.5 cm, and through the internal fistulous passage with a single-pronged hook, it is turned into the intestinal lumen, then the internal opening of the fistulous passage is sutured by applying a Z-shaped suture with the capture of the muscles of the internal sphincter, followed by ablation of the distal fistulous passage with a surgical laser " Lakhta-Milon" intraluminally using a light guide with circular radiation with a wavelength of 1470 nm, a power of 9 W, at a speed of 1 mm / s.

The proposed method was operated on 6 patients in the surgical department of CHUZ KB "RZD-Medicine" in Astrakhan.

Examples of clinical implementation of the method

Example. Patient A., 23 years old. Hospitalized with a diagnosis of chronic paraproctitis. Complete extrasphincteric pararectal fistula. Complaints of periodic pain in the anus, purulent discharge from the anus. When viewed in the anus in the knee-elbow position at 5 o'clock, an external fistulous opening 1.5 × 1.5 mm is visualized, the skin around is compacted. When pressed, a serous discharge is released from the fistulous passage. During revision with a probe, the fistula passes through the sphincter fibers, goes towards the rectum at a depth of 4 cm. The probe is brought out through the internal opening at 6 o'clock. Sphincter tone is normal. Under local anesthesia with potentiation, the fistulous tract was washed with a 0.05% aqueous solution of chlorhexidine, treated with a Volkmann spoon, the fistulous tract was excised through an incision in the projection of the intersphincteric space, not reaching the internal opening of 0.5 cm, and through the internal fistulous tract it was wrapped with a single-toothed hook into the lumen of the intestine, then the internal opening of the fistulous tract was sutured by applying a Z-shaped suture with the capture of the muscles of the internal sphincter, followed by ablation of the distal fistulous tract with a Lakhta-Milon surgical laser intraluminally using a light guide with circular radiation with a wavelength of 1470 nm, a power of 9 W, at a speed of 1 mm/s.

The postoperative period was pain-free. On the 5th day he was discharged from the department in a satisfactory condition. Further observation took place on an outpatient basis. At the control examination after six months, there were no relapses.

The advantages of the invention are:

- laser treatment of the fistulous tract has a pronounced sanitizing and coagulating effect without damaging the sphincter;

- screwing in the proximal part of the fistula and applying a Z-shaped suture to the internal opening of the fistula with the capture of the muscle of the internal sphincter prevents the formation of a rough scar, residual cavity and reduces the risk of recurrence.

The proposed method can be recommended for use in clinical practice for the treatment of extrasphincter pararectal fistulas.

Claims (1)

A method for treating extrasphincteric pararectal fistulas by treating the fistulous tract with subsequent use of a surgical laser, characterized in that under local anesthesia with potentiation with a bellied probe, the fistulous tract is revised through the external opening, the fistulous tract is washed with a 0.05% aqueous solution of chlorhexidine, followed by treatment using a Volkmann spoon, through the incision in the projection of the intersphincter space, the fistulous tract is crossed, not reaching the internal opening of 0.5 cm, which is turned into the intestinal lumen with a single-pronged hook, and the internal opening of the fistulous tract is sutured by applying a Z-shaped suture with the capture of the muscles of the internal sphincter, with subsequent ablation of the distal part of the fistulous tract with a surgical laser "Lakhta-Milon" intraluminally using a light guide with circular radiation with a wavelength of 1470 nm, a power of 9 W, at a speed of 1 mm/s.